Priebe et al.

BMC Public Health 2011, 11:187

http://www.biomedcentral.com/1471-2458/11/187

RESEARCH ARTICLE Open Access

Good practice in health care for migrants: views

and experiences of care professionals in 16
European countries
Stefan Priebe1*, Sima Sandhu1, Snia Dias2, Andrea Gaddini3, Tim Greacen4, Elisabeth Ioannidis5, Ulrike Kluge6,
Allan Krasnik7, Majda Lamkaddem8, Vincent Lorant9, Rosa Puigpinsi Riera10, Attila Sarvary11, Joaquim JF Soares12,
Mindaugas Stankunas13, Christa Stramayr14, Kristian Wahlbeck15, Marta Welbel16, Marija Bogic1

Abstract
Background: Health services across Europe provide health care for migrant patients every day. However, little
systematic research has explored the views and experiences of health care professionals in different European
countries. The aim of this study was to assess the difficulties professionals experience in their service when
providing such care and what they consider constitutes good practice to overcome these problems or limit their
negative impact on the quality of care.
Methods: Structured interviews with open questions and case vignettes were conducted with health care
professionals working in areas with high proportion of migrant populations in 16 countries. In each country,
professionals in nine primary care practices, three accident and emergency hospital departments, and three
community mental health services (total sample = 240) were interviewed about their views and experiences in
providing care for migrant patients, i.e. from first generation immigrant populations. Answers were analysed using
thematic content analysis.
Results: Eight types of problems and seven components of good practice were identified representing all
statements in the interviews. The eight problems were: language barriers, difficulties in arranging care for
migrants without health care coverage, social deprivation and traumatic experiences, lack of familiarity with the
health care system, cultural differences, different understandings of illness and treatment, negative attitudes
among staff and patients, and lack of access to medical history. The components of good practice to overcome
these problems or limit their impact were: organisational flexibility with sufficient time and resources, good
interpreting services, working with families and social services, cultural awareness of staff, educational
programmes and information material for migrants, positive and stable relationships with staff, and clear
guidelines on the care entitlements of different migrant groups. Problems and good care components were
similar across the three types of services.
Conclusions: Health care professionals in different services experience similar difficulties when providing care to
migrants. They also have relatively consistent views on what constitutes good practice. The degree to which these
components already are part of routine practice varies. Implementing good practice requires sufficient resources
and organisational flexibility, positive attitudes, training for staff and the provision of information.

* Correspondence: s.priebe@qmul.ac.uk
1
Unit for Social and Community Psychiatry, London and the Barts School of
Medicine and Dentistry, Queen Mary University of London, Newham Centre
for Mental Health, London, E13 8SP, UK
Full list of author information is available at the end of the article

2011 Priebe et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Priebe et al. BMC Public Health 2011, 11:187
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Background
Migration to European countries has increased since
2000 [1]. Estimates suggest that in 2005, 8.5% of the EU
population consisted of migrants, with an additional
5.6 million arriving between 2005 and 2009 [2]. A
central challenge for Europe, with its increased propor-
tion of migrants, is the provision of accessible, equitable,
and good quality health services for all.
Most research on health care for migrants has focused
on access and use of services by migrants, with much of
the literature coming from the US [3,4], Canada [5],
Spain, [6-8], Denmark [9], the UK [10] and Sweden
[11,12]. Studies suggest that migrants experience
unequal access to care [13], and outline the complexity
of health care entitlements of migrants [14-16].
This study did not address the problems of accessing
care, but the quality of care provided to migrants once
they are in a service, an issue which has received compara-
tively less attention in the literature, but is of central
importance to millions of migrants who are treated in
health services across Europe every day. Numerous health
care professionals in different European countries face the
challenge of providing the best possible care to migrant
patients, and many of them have a wealth of experience
[17,18]. Yet, there has been little systematic research
exploring their views and experiences on what they see as
the problems and what they regard as good practice.
This study explored the views and experiences of
those health care professionals in different types of ser-
vices across Europe, who provide care to migrants on a
daily basis. The aim was to assess what problems they
experience in their service, and what they view as good
practice to overcome these problems or limit their nega-
tive impact on the quality of care.
Methods
Recruitment and Sampling
As part of the EC funded project Best Practice in
Health Care Services for Immigrants in Europe
(EUGATE) [19] interviews were conducted with health
care professionals in 16 European countries (covering
more than 85% of the EU population) to identify their
experiences and views of providing health care to
migrants.
To ensure the participants had sufficient experience of
providing health care to migrants, each participating
country was asked to identify and recruit participants
from areas where migrant population levels were parti-
cularly high. The plan was to focus on the three districts
in each capital, or another urban context, with the high-
est proportion of immigrants.
A refined definition of migrants was used to aid classi-
fication of areas high in migrant groups. Migrants were
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defined as persons who were born outside the country
of current residence, and who were aged between 18
and 65 years. In line with EU directives; regular immi-
grants (e.g. labour immigrants), refugees, asylum seekers,
victims of human trafficking, and illegal/undocumented
immigrants were all encapsulated in this definition.
Once areas were identified, for each of the three dis-
tricts in each country, participants were recruited from
three primary care practices (i.e. 9 per country, total n =
144), and one each from an accident and emergency
hospital department (3 per country, total n = 48), and a
community service for patients with mental illnesses (3
per country, total n = 48). In selecting primary care
practices we aimed to include those with the highest
number of migrant patients or, in the absence of such
data, the biggest ones in the area. Whilst usually there
was only one A&E department in each area, for commu-
nity mental health services we aimed to select the lar-
gest one in the given area. The list of selected areas and
health service in all 16 countries are shown in Table 1.
We approached the selected service and asked for an
interview, preferably with a practitioner with the largest
experience in providing health care to migrants in the
service. The decision as to who was to be interviewed in
the study was made by the service.
The Interviews
Face-to-face interviews were conducted between 2008
and 2010. A structured interview schedule was devel-
oped in English and piloted in each participating coun-
try. Based on the experiences of the pilot phase, the
schedule was refined and finalised. The final version of
the schedule was translated into the languages of the
participating countries. It was presented in two parts.
The first part of the interview focused on open ques-
tions about general experiences, in particular problems
and strengths in providing health care to migrants
within the service. The second part consisted of open-
ended questions about patients represented in three
case vignettes. These cases were modified to suit the
three types of services (primary care, A&E, and commu-
nity mental health) and aimed to specify differences and
similarities in treatment for migrants in comparison to
indigenous populations (as can be seen in the text from
the vignettes below).
Primary Care
Illegal immigrant A male, 28 years old, coming from
[insert country], presents with pain when urinating and
has a slight fever. He does not speak any language that
the doctor understands. He has no insurance, no identi-
fication and no residency permit.
Refugee A refugee woman, 39 years old, from [insert
country], presents with headache, anxiety, sleeping
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Table 1 Sampled countries and corresponding health service areas

Country Selected Cities Selected Primary Care Areas Selected Mental Health Care Areas Selected A & E Areas
AUSTRIA Vienna Rudolsheim-Fnfhaus, Ottakring, & Rudolsheim-Fnfhaus, Ottakring, & Leopoldstadt, Ottakring, &
Brigittenau. Brigittenau. Brigittenau.
BELGIUM Brussels Saint Josse, Schaerbeek, & Molenbeek Saint Josse, Schaerbeek, & Molenbeek Saint Josse, Schaerbeek, &
Brussels City
DENMARK Copenhagen Nrrebro, Valby, Bispebjerg, Brndby, Areas within Bispebjerg Hospital, Bispebjerg Hospital,
Albertslund, & Rdovre Hvidovre Hospital, & Glostrup Hospital Hvidovre Hospital, &
Glostrup Hospital
FINLAND Vaasa, Pietarsaari, Vaasa, Pietarsaari, & Oravais, Vaasa, Pietarsaari, & Malax Vaasa, Pietarsaari, & Oravais,
Oravais, Malax
FRANCE Paris 18th & 19th Arrondissments of Paris & 18th & 19th Arrondissments of Paris & Bichat, Lariboisiere, & La
Aubervilliers of Seine-St-Denis Aubervilliers of Seine-St-Denis Roseraie
Department Department
GERMANY Berlin Tiergarten, Wedding, & Kreuzberg Tiergarten, Wedding, & Kreuzberg Tiergarten, Wedding, &
Kreuzberg
GREECE Athens Vari, Vyronas, Galatsi, Thrakomakedones, Central Athens Voula & Thrakomakedones
& Elefsina
HUNGARY Budapest Terzvros, Erzsbetvros, Kbnya, Erzsbetvros, Kbnya, & Pesterzsbet Erzsbetvros, Kbnya, &
Zugl, & Csepel Pesterzsbet
ITALY Rome Districts I, VIII, & XX Districts I, VIII, & XX Districts I, VIII, & XX
LITHUANIA Kaunas Nine largest PHC out of 11 Aleksotas & Zaliakalnis Downtown Kaunas,
Zaliakalnis, & Silainiai district
NETHERLANDS Amsterdam, Amsterdam, Utrecht, & Rotterdam Amsterdam, Utrecht, & Rotterdam Amsterdam, Utrecht, & the
Utrecht, Rotterdam, Hague
Hague
POLAND Warsaw Mokotow, Praga Poludnie, & Mokotow, Praga Poludnie, & Mokotow, Praga Poludnie, &
Srodmiescie Srodmiescie Srodmiescie
PORTUGAL Lisbon Amadora, Loures, & Lisboa Amadora, Loures, & Lisboa Amadora, Loures, & Lisboa
SPAIN Barcelona Cuitat Vella, Eixample, Sants Montjuic, & Cuitat Vella, Eixample, & Nou Barris Cuitat Vella, Eixample,& Nou
Nou Barris Barris
SWEDEN Stockholm Central, South East, & South West Central, South East, & South West Central, South East, & South
West
UNITED London Hackney, Tower Hamlets & Newham Hackney, Tower Hamlets & Newham Hackney, Tower Hamlets &
KINGDOM Newham

problems and stomach ache. She has very little com-
mand of the language of the host country. She brings
her 12 years old daughter along, who speaks the lan-
guage of the host country very well.
Labour immigrant A [insert nationality] woman,
40 years old, labour immigrant, widow, with two chil-
dren 10 and 15 years old, asks for medication for her
lower back pain. She speaks the language of the host
country reasonably well, is working legally in a cleaning
company and wants to go back to work urgently.
Accident & Emergency Department
Illegal immigrant The patient arrived in the host coun-
try as an illegal immigrant about 1 year ago. He is
25 yrs of age and of [insert a country] origin. He does
not speak any language that the A&E staff understands
and presents with an intense lower abdominal pain.
Refugee The female patient is 19 yrs of age and arrived
from [insert a country] 10 months ago. She has refugee
status and speaks only [insert language of origin] and a
few words of English. She is in her fifth month of
pregnancy and has a serious complication (pre-eclampsia).
She is reluctant to be examined by a male doctor.
Labour immigrant The male patient is 35 yrs of age
and arrived from [insert a country] two years ago. He
has a regular residence permit. He was brought to A&E
by the police because of his aggressive behaviour follow-
ing heavy drinking. He suffered external head injuries
in a fight. He is fully conscious and accessible for
examination.
Mental Health Services
Illegal immigrant The patient arrived in the host coun-
try as an illegal immigrant about 1 year ago. She is
25 yrs of age and of [insert nationality] origin. She does
not speak the language of the host country, has no
social contacts and appears severely depressed.
Refugee The male patient is 22 years of age, came to the
host country from [insert country] a year ago and has
refugee status. He speaks a few words of the language of
the host country. He appears to have persistent auditory
hallucinations and feels persecuted.
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Labour immigrant The female patient is 45 yrs of age
and arrived from [insert country] two years ago. She has
a regular residence permit, speaks the language of the
host country well and suffers from a bipolar disorder
with frequent and prolonged manic episodes.
The country of origin of the migrants in the vignettes
varied slightly between countries to ensure that the ori-
gin of the migrant was consistent with the demographic
composition of migrants in the participating country, so
that the vignettes presented a realistic scenario to the
interviewees in each country. In all other ways, the case
vignettes and questions were identical across countries.
Demographic information and professional standing of
the interviewees were documented and the interviews
were audio-taped in the majority of cases. When this
was not possible, responses were documented in writing.
Informed consent was obtained prior to the interviews,
and the study was approved by relevant ethics commit-
tees in countries where this was required. Ethics
approval for the study was obtained in Portugal through
the University Hospital S. Joo. In other countries ethics
approval was not required because no patient data was
recorded, because the study was regarded as service eva-
luation without the need for an ethical review.
Data Analysis
All of the 240 interviews were audio-taped or recorded
in writing and transcribed verbatim, ensuring the
removal of any identifying information to maintain
anonymity. The prepared transcripts were subjected to
thematic content analysis [20]. This process was deemed
the most suitable for interpreting the textual data in a
systematic way, from classifying codes to identifying
emergent themes.
The first stage was to code the data from the initial
interview transcripts line-by-line, which was conducted
in each of the participating centres. The codes and cor-
responding textual extracts were then used to develop a
codebook, which was translated into English, reviewed
and finalised amongst the researchers in all participating
countries. The resulting codebook consisted of a list of
codes, accompanied by a brief and a more comprehen-
sive definition, and illustrated with examples. The code-
book was utilised to code the entire data corpus, with
strategic checks made after coding of the first six inter-
view transcripts from each country. The validity of the
codes was checked against the data extracts to ascertain
grounding in the transcribed data. Discrepancies in cod-
ing across centres were picked up early in the analysis
and clarified with verifications, further to those sum-
marised in the codebook. The second stage of the analy-
sis was the clustering of codes into emergent categories,
which were then structured and grouped to form over-
arching themes [21,22]. To ensure the themes and
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categories consistently represented the data corpus
across all participating centres, final verification checks
were made between each participating centre and the
coordinating centre.
Data from all parts of the interview and from all coun-
tries were included in frequency counts of themes. This
numerical depiction of content was used to specify the
frequency of the problems and good practice compo-
nents and compare those frequencies across services.
Results
Participants
The majority of interviewees were practitioners (n =
214) including doctors (156), nurses (44), psychologists
(7), physiotherapists (4) and social workers (3). The
remaining participants were either administrators or
managers, some of whom were also qualified health care
professionals (n = 26).
Differences in further treatment for migrants
The majority of respondents (74%) asserted that, in gen-
eral, treatment for migrants after the initial contact
would not differ from that for non-migrant patients.
When specifically asked in case vignettes about different
further pathways depending on the immigration status,
for the labour migrant vignette over two-thirds (147
participants) explicitly said that there would be no dif-
ference in further treatment pathways. However, for
refugees and undocumented migrants only one or two
participants respectively reported no difference in
further treatment pathways.
Problem Areas
Eight problem areas were identified, which are listed in
Table 2. These are comprehensive and include all pro-
blems mentioned in the 240 interviews. The problems
are here presented in the order of the frequency of
interviews in which they have been raised.
1) Language barrier
Language and communication problems were most
commonly reported, with frequent references made to
a language barrier between practitioners and patients.
Concerns were expressed for migrants inability to
communicate their problems due to language difficul-
ties, with the risk of being misunderstood and, ulti-
mately, misdiagnosed. Respondents described how
extensive physical examinations and diagnostic tests
were sometimes required to compensate for the inabil-
ity to communicate verbally. Administrative procedures
were also prolonged and complicated through poor
communication.
Some interviewees outlined associated problems with
no or restricted access to interpreting services, which
often resulted in the use of the patients child, or
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Table 2 Frequency of problem areas reported amongst interviewees by service type

Themes Service Type (%) Totals (%)
Problem Areas Primary Care Mental Health A&E All Services
Language barrier 137 (95) 45 (94) 46 (96) 228 (95)
Difficulties in arranging care for migrants without health care coverage 124 (86) 33 (69) 28 (58) 185 (77)
Social deprivation and traumatic experiences 101 (70) 41 (85) 26 (54) 168 (70)
Lack of familiarity with the health care system 92 (64) 27 (56) 31 (65) 150 (63)
Different understandings of illness and treatment 79 (55) 36 (70) 24 (50) 139 (58)
Cultural differences 74 (51) 26 (54) 38 (79) 138 (58)
Negative attitudes among staff and patients 58 (40) 21 (44) 21 (44) 100 (42)
Lack of access to medical history 24 (17) 10 (21) 13 (27) 47 (20)

another family member translating during consultations.
This was especially problematic in sensitive cases.
There is often a significant language barrier. If
everything has to be translated, you lose half the
time. Often a child or grandchild is translating, but
then you cant ask personal intimate things anymore.
A ten year old girl cant translate the menstruation
problems of her mother. Thats really a problem.
(Netherlands, ID 212, Primary Care)
Family members may also choose to be selective in
what they translate, summarising or even censoring the
communication between the patient and the doctor.
When it is a family member who comes to translate,
he translates what he wants, its only interpreta-
tion... (Belgium, ID 27, Primary Care)
Involving a professional interpreter however may also
come with problems. Concerns were expressed for how
involving a third party would impact on the patient-
practitioner relationship. Third party involvement also
led some participants to be concerned over confidential-
ity issues, especially when the interpreter was from the
patients own community.
2) Difficulties in arranging care for immigrants without
health care coverage
Respondents discussed the difficulties in providing care
for undocumented immigrants, who had no entitlements
to mainstream health care services. Some professionals
reported that the entitlements of different patient groups
required clarification. Others mentioned that they had
sufficient information to know what treatments they
could offer, where the patient could seek further help, or
how the treatment should be funded. Awareness of the
legal situation may put practitioners into a dilemma.
a big problem for doctors, because in theory, unin-
sured patients should cover the costs of their treat-
ment by themselves. But for most immigrants it is
impossible... And doctors are in a situation with no
good solution - from an ethic point of view they
should provide treatment, from a legal point of view
- they shouldnt. (Poland, ID 234, Primary Care).
Most interviewees said that they would always provide
emergency care if required. They described restricted
access to laboratorial tests, scanning and other specialist
pathways for migrants without coverage. Some intervie-
wees attempted to circumnavigate the coverage problems
by submitting laboratory samples in their own name, pre-
scribing the patient with a cheaper medicine they could
afford, or choosing to register the patient in an alterna-
tive manner. Some interviewees expressed concern that
they would not be able to contact the patient again if
tests raised abnormal results, or that migrants fearful of
deportation would risk using fake identification or some-
one elses documents to receive care.
3) Social deprivation and traumatic experiences
Over two-thirds of the interviewees reported problems
arising from stressful experiences for migrants. Recent
migrant patients were viewed as being more socially mar-
ginalised, from poorer backgrounds, unemployed, strug-
gling to learn a new language, or to integrate, and possibly
traumatised from experiences of war and conflict.
...that lady from the Congo had her foot sawn off as
a form of torture. Other things like that, multiple
rape, people who have had their lips cut off, or their
whole family murdered in front of them... (UK, ID
305, Primary Care)
Some of these specific socioeconomic stressors had a
direct impact on treatment.

Unfortunately, sometimes even legal immigrants are ...the difference is, that there is more [treatment] and
not covered by general health care insurance. This is less prevention. That I just cant put her on sick-leave,
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that I cant advise her to change her job - how should
she attend a training, and let her children starve, that
is not possible and that is the difference. (Austria, ID
2, Primary Care).
Some respondents held the view that resolving socioe-
conomic and legality issues were of more importance to
many patients than resolving health problems.
4) Lack of familiarity with the health care system
A lack of familiarity with the health care system was
regarded as common among recent immigrants.
A&E services are often the only care access many
migrants have - because they dont know how the sys-
tem works. (France, ID 806, A&E).
Not fully understanding the health care system affects
the treatment available. Interviewees reported cases
where available resources and services were underused
by migrants, because they were not aware of their exis-
tence. Furthermore, respondents discussed that previous
experience in other health care systems often led
migrants to have different expectations of the roles of
doctors and patients. Different understandings of the
patient-clinician relationship may result in uncertainty
and mistrust, if experiences differ greatly from expecta-
tion. Interviewees regarded the role of doctors as given
greater precedence amongst certain migrant patients,
who may have unrealistic expectations about the capa-
city of doctors to sort various physical and social pro-
blems within short consultations.
5) Different understandings of illness and treatment
Participants reported problems linked specifically to dif-
ferent understandings of the given illness of a migrant
patient and the treatment options. Expressions of aetiol-
ogy, symptoms, and pain made a diagnosis difficult to
establish, especially when understandings of these con-
cepts greatly differed between the patient and
practitioner.
Respondents discussed the challenges in treating
migrant patients with different understandings of the
human body, which occasionally resulted in patients
deciding not to follow the recommended treatment, or
agreeing after some resistance.
I had this woman from Somalia who said her back
was hurting and her understanding of the pain was
that she had some air which was moving from one
side of the back to the other [...] she wanted me to
perforate the shoulder so that the air could get out. It
was very difficult to explain why I just gave her
tablets because her perception of her body is comple-
tely different. [...] Even with an interpreter it was
very difficult to explain so we had to find my
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anatomy book and show [...] her problem with the
back was with muscles and that there was no air
here. She kind of understood though she did not look
completely convinced, but she took the pills and it
helped. (Denmark, ID 49, Primary Care)
6) Cultural differences
Whilst the previous problem was specifically linked to
the understanding of the given illness and its treatment,
interviewees reported also more general differences in
cultural norms, religious practices and customs as
potential complications to direct examination and treat-
ment. Interviewees reported concerns regarding appro-
priate engagement in physical examinations, preserving
and respecting religious restrictions on physical contact
and cultural taboos.
...members of Muslim religious communities, there
are shame barriers that we do not have: the husband
expects to attend the treatment session. In certain
treatment- the areas of sex, anal region are taboo.
(Germany, ID 101, A&E)
While most services were able to offer treatment from
either gender if requested, others were not. According
to the respondents, this had on occasion resulted in
patients refusing care or unwilling to disclose sensitive
information.
Interviewees noted that some European treatments
and traditions may be difficult for migrants to embrace,
particularly when they involve therapies and treatments
outside of medication.
Different cultural values and beliefs make it difficult
for the doctor to use psychotherapeutic procedures
(Greece, ID 122, Mental Health).
Respondents also discussed cultural differences in
terms of practical issues such as not attending appoint-
ments, turning-up late, or seeking consultation outside
of opening hours. Often this was discussed as leading to
disappointment and frustration, as patients would be
asked to make another appointment. There were also
concerns for the impact this would have on the service,
with delays to other appointments, and a general strain
on time and resources.
7) Negative attitudes among staff and patients
Interviewees reported a lack of trust of some migrant
patients towards staff. Distrust towards practitioners and
interpreters originating from countries where patients
previously experienced political or religious conflict
were reported in this context. Certain patients were
reported as being explicit in their requests to be seen by
another member of staff, or withholding information,
based on these grounds. Negative attitudes towards staff
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and sometimes hostile behaviour were largely attributed
to cultural differences, misunderstandings, or the feeling
of the patients that they were not being taken seriously.
Fears of discrimination were mentioned in explana-
tions of patient reticence, often based on current and
previous societal experiences, or opinions reported in
the media. However, staff behaviour towards migrant
patients may also perpetuate this fear of discrimination.
Many migrants experience discrimination and rejec-
tion within the healthcare system; being sent away,
being treated unkindly, treated as if they are stupid,
while they do not understand the language. These
experiences are taken along in the doctor-patient
relationship. I can notice the distrust of new clients
at their first consultation with me. (Netherlands, ID
214, Primary Care).
8) Lack of access to medical history
Finally, lack of access to a medical history was reported
as problematic, especially for undocumented migrants. If
such information was available, it was usually in a for-
eign language. Respondents further discussed the com-
plications associated with not knowing whether patients
had allergies, vaccinations, or previous health problems.
They were concerned that lack of contact details and
nationality made decisions regarding consent and next
of kin problematic.
Differences between types of services
Most problems were similarly raised in all three types of
services. Primary care services more often mentioned
difficulties in arranging further care, whilst community
mental health services put more emphasis on the social
stressors for migrants and A&E departments on differ-
ent cultural norms. Negative attitudes and lack of access
to medical history were raised as problems in 15 coun-
tries; the other problem areas were raised in all 16
countries.
in the interviews. They are summarised in Table 3 and
reported below in order of frequency. Statements on
good practice were considered in the themes indepen-
dently of whether respondents mentioned them as an
existing strength of their service, or a suggestion for
future improvements.
1) Organisational flexibility with sufficient time and
resources
Almost all respondents mentioned aspects relating to
organisational flexibility, including sufficient time,
resources and individualisation of care.
Many practitioners reported booking double ses-
sions, especially when an interpreter was involved,
and giving migrant patients more time to ensure that
they were heard and understood. Where limited time
and resources were reported, the respondents sug-
gested that staff could be employed to specifically
manage social and administrative issues, freeing more
time for practitioners to see patients in a health care
capacity.
...to have more professionals with time available to
provide information to these patients so they can feel
that they have a place where they can go and ask
their questions. (Portugal, ID 244, A&E).
Interviewees discussed the importance of structuring
regular staff meetings to deal with the problems arising
in health care to migrants.
Some services faced restrictions on treating undocu-
mented migrants. To overcome this barrier to further
care, suggestions were made to seek funding for treat-
ment from Non Governmental Organisations, sending
patients to clinics specialising in providing care to undo-
cumented migrants, providing cheap or free medication,
giving private prescriptions, or registering undocumen-
ted migrants in an alternative way (e.g. as a tourist).

Components of good practice I prescribe the medicines for my own name, if the
Seven themes describing different components of good patient has no money for it. (Hungary, ID 146,
practice emerged and covered all components mentioned Primary Care).

Table 3 Frequency of components of good practice reported amongst interviewees by service type
Themes Service Type (%) Totals (%)
Components of Good Practice Primary Care Mental Health A&E All Services
Organisational flexibility with sufficient time and resources 138 (96) 48 (100) 48 (100) 234 (98)
Good interpreting services 142 (99) 38 (79) 38 (79) 218 (91)
Working with families and social services 67 (47) 48 (100) 18 (38) 133 (55)
Cultural awareness of staff 58 (40) 32 (67) 22 (46) 112 (51)
Education programmes and information material for migrants 66 (46) 15 (31) 23 (48) 104 (43)
Positive and stable relationships with staff 62 (43) 13 (27) 16 (33) 91 (38)
Clear guidelines on care entitlements of different groups of migrants 15 (10) 8 (17) 4 (1) 27 (11)
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In practice many respondents reported that staff
would first treat patients and then possibly consider
issues of entitlement and insurance. Respondents also
mentioned that services to migrants could be improved
with the use of more documentation, even for those
with no legal residency. Recommendations were made
for establishing databases with medical histories.
Several interviewees mentioned close geographical
proximity to immigrant populations as a strength of
their service. Providing a local service for migrants
reduced problems associated with keeping appoint-
ments, and the cost of transportation.
Respondents spoke of the importance of a flexible and
individualised approach for migrants within mainstream
care, with more walk-in sessions, open appointment
slots, and advocacy services.
2) Good interpreting service
Good interpreting services were mentioned in almost all
of the interviews and respondents were specific in what
was required for a good quality interpreting service.
Qualitative interpreting services, so that the inter-
preter knows the medical terminology and also
understands the professional discretion (Finland, ID
73, Primary Care).
They suggested that this could be achieved through
professional interpreters, recommending improved
access to interpreting services, including the availability
of interpreters at the reception point and facilities for
multiple languages. The provision for a permanent in-
house interpreting service was discussed by some, as
were same-language therapists for patients receiving
talk-based therapies. Others emphasised improving
migrant patients command of the national language as
the best possible long-term answer to reducing language
barriers.
Communication through a professional interpreter was
not always viewed as entirely helpful. Some interviewees
preferred using relatives or friends as interpreters
instead, because of their ability to provide more compre-
hensive information about the patient, as well as having
the patients trust. Respondents reported using the inter-
net to assist in translation, by the use of search engines
or web pages with medical advice and information from
the patients country of origin.
3) Working with families and social services
Just over half of the respondents suggested collaboration
with social services and families as important for good
practice in migrant health care. Central to this theme
were good contacts with social services and the sharing
of information.
Interviewees explicitly mentioned engaging with
community centres to connect migrant patients to
Page 8 of 12
the wider community. Some reported contacting reli-
gious leaders and non-statutory agencies to assist
migrants in getting in touch with their local commu-
nity. Concerns were also raised about migrants
becoming isolated. Respondents addressed attempts
made by health care staff in some services to con-
tact the patients family or friends, even if they were
in another country.
Participants raised concerns that in some cases the
patients living conditions maybe exacerbating an ill-
ness or limiting recovery and discussed instances
where they had attempted to find solutions to the
patients personal and social problems. For example,
some referred patients with housing problems to chari-
ties with housing facilities. Other health services have
Citizens Advice Bureau advisors, physiotherapists, cul-
tural welfare advisors, and family action advisors to
assist immigrants with different needs in one service.
Respondents discussed the benefits of dealing with
health, administrative and legal issues in one place.
They reported often to encourage migrant patients to
get in touch with refugee organisations, projects for
immigrant women, language learning centres and other
training courses.
4) Cultural awareness of staff
Cultural awareness was reported as important for good
practice. Some respondents viewed the training of staff
in different cultural and religious practices as core to
the delivery of satisfactory and respectful care to
migrant patients. Some spoke of developing expertise in
the treatment of migrant patients through experience
and exposure, such as being located in a multicultural
community, or being known as a culturally sensitive
service.
Respondents made specific recommendations for
topics on cultural sensitivity to be covered in practi-
tioner training courses and university education. They
further suggested that courses should include informa-
tion on migrant specific diseases, cultural understand-
ings of illness and treatment, and information pertaining
to cultural and religious norms and taboos.
There are the lack of knowledge how to work with
this type of patients. Doctors are lacking legal, cul-
tural, specific medical information about this. It
would be good to organize a short training course in
this field. (Lithuania, ID 186, A&E).
According to the respondents, such knowledge
enabled them to reach more accurate diagnoses and
provide appropriate treatments, while meeting patient
needs for cultural acceptance and understanding. The
presence of migrant staff was also flagged up as increas-
ing the awareness of migrant needs and assisting with
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understanding culture and language issues.
It is a great strength that we have staff of different
ethnic background. We can learn from them once in
a while when there is an episode where we think
what just happened here? Then it is a gift to have
an employee who is able to say what they think it is
about. And often it is. In acute situations we have a
language which we need here and now... (Denmark,
ID 44, Mental Health).
5) Educational programmes and information material for
migrants
Interviewees suggested that instructive programmes and
information material be produced for migrants about
the host countrys health care system. Such information
was viewed as helpful for migrants to access appropriate
services and seeking effective treatment. Suggestions
were made for community health projects, or evening
meetings, where medical staff could explain and educate
migrants about how the health care system works, and
how to foster a healthy lifestyle.
They should design a welcome process adapted to
immigrant people to explain the health care system,
counselling etc. For example, they should have an
interview with the immigrant patients to inform
them about the health care system and the service
roles. (Spain, ID 265, Primary Care).
As one way of providing such information respon-
dents suggested the use of leaflets in multiple languages,
explaining the health care system and avenues for acces-
sing services. Some interviews felt this took some pres-
sure off practitioners, so that they would spend less
time explaining the system and more time providing
direct patient care. In addition, interviewees purported
that this would reduce patient disappointment, as
awareness of what can be expected from each service
and staff would be unambiguous. However, some
respondents cautioned that migrant patients may still
need assistance to be guided to leaflets and, where lit-
eracy is an issue, more assistance would be required
than just a leaflet.
6) Positive and stable relationships with staff
Over a third of all respondents pointed towards posi-
tive relationships between staff and patients, and conti-
nuity of care as components of good practice. They
discussed the necessary features for a positive relation-
ship, which included respect, warmth, being welcom-
ing, listening and responding effectively. Some
respondents spoke of having welcoming policies in
place, which ensured that patients are given individual
attention and eased processes for them where possible.
The promotion of non-judgmental, open minded and
Page 9 of 12
equitable staff was also mentioned in responses under
this theme.
Consistency of staff was seen as important for achiev-
ing familiarity and building a positive and trusting rela-
tionship.
I have built a relationship with my clients, and have
gradually come to know them. I am a familiar per-
son, and they know they can always contact me. If I
am absent, they can contact a colleague of mine,
with whom they are also familiar. (Netherland, ID
214, Primary Care).
Respondents further reported that seeing a different
clinician at every appointment had a negative impact on
patients experience of the service, especially when they
had to explain their medical history repeatedly in every
consultation.
7) Clear guidelines on care entitlements of different groups
of migrants
Several respondents suggested clearer information and
guidelines on what type of care different migrant groups
are entitled to. They reported the benefits from courses
on migrant health care rights and other legal issues.
Included under this theme were suggestions for infor-
mation on how to gain funding for treating undocumen-
ted migrants. Some governments legally allow
practitioners to treat undocumented migrants if their
condition was life threatening. However, respondents
reported that transparency was needed on what was
considered a life threatening condition.
Differences between types of services
Collaboration with families and social services was more
often reported as important in community mental health
services, whilst the other components of good practice
were raised by interviewees in the three service types
with a similar frequency. Clear guidelines were sug-
gested in 10 countries, education programmes in 14
countries, positive relationships in 15 countries, and all
other good practice components in all 16 countries.
Discussion
Main findings
In interviews with health care professionals in different
types of services across Europe, eight problem areas
were identified in the delivery of care to migrants. Seven
components of good practice were suggested to over-
come these problems or limit their potentially negative
impact. Problem areas and good practice components
are comprehensive, i.e. they covered all statements made
in 240 interviews in 16 countries. Most problems and
good practice components were raised in all countries
and in more than 50% of the interviews, although the
specific aspect and emphasis for each theme often varied
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among interviews. Problems and good practice compo-
nents may therefore be seen as valid across Europe and
different types of health services. The study findings
provide a systematic and inclusive picture of the difficul-
ties in providing health care to migrants and the possi-
ble solutions.
Interviewees were mindful of migrant specific difficul-
ties and barriers, and believed that care to migrants was
complicated by issues of language, culture, attitudes,
entitlements, lack of awareness, and experience. The
good practice components may be seen as more general,
and several of them may apply not only to migrants, but
to wider groups of patients. This reflects the overriding
position of professionals that good practice in service
delivery should be achieved by dispensing care on an
individual basis, considering personal need, rather than
focusing on group stereotypes and customary notions
that migrants needs may differ greatly from indigenous
patients. The findings provide support for treating
migrant patients in mainstream health care services
rather than segregating them out.
Good practice for migrants however may require addi-
tional and specific efforts. These include altering service
delivery with modifications of routine practice, such as
giving patients with language needs more time, or seek-
ing collaboration with social services that would be able
to assist in legal and/or social issues. Problems and
good practice components were largely consistent across
the three very different types of services, i.e. primary
care, emergency hospital departments, and community
mental health services for patients with long term
disorders.
Strengths and Limitations
The study has a number of strengths: a) It is a large
study using similar methods across 16 countries; b) the
findings are based on a total of 240 interviews from
countries with different histories of immigration so that
saturation of findings can be assumed; c) we used simi-
lar selection criteria and the same interview schedule
(apart from the origin of migrants in case vignettes) for
all countries; d) we implemented a rigorous and consis-
tent method for the analysis of the material which - to
our knowledge - is unique for a qualitative study invol-
ving so many countries and languages, and the process
was consistently quality managed; and e) the interview
schedule was specific to health care delivery rather than
the more often studied issue of access.
There are however also several limitations: a) the sam-
pling frame for selecting areas was not strictly adhered
to in all countries, and whilst most of the areas were in
capitals this does not apply to all of them; b) intervie-
wees were self-selected which may have introduced a
bias, e.g. preferring professionals with a particular
Page 10 of 12
interest in migrant health and with specifically positive
or critical views; c) statements may have been influenced
by response tendencies, e.g. in line with the social desir-
ability of answers, and reflect only personal statements;
we have no independent information about what actu-
ally happens in the participating services and do not
know the view of the migrant patients; and d) transla-
tions into English were required for the final analysis,
information may have been lost in translation as a
consequence.
Comparisons with the literature
The problems areas in providing care to migrants iden-
tified in this study are consistent with those found in
previous research. In a review of migrant health in the
EU [13], language and literacy barriers, entitlement
issues, cultural differences in expectations, and misun-
derstanding of Western medicine were suggested as
impeding the access to and delivery of optimal health
care. A negative impact of social migration stressors on
both mental and physical health and migrant specific
needs stemming from a lack of economic resources and
limited social networks were noted in the literature on
labour migrants and refugees [10,23,24].
Language barriers and the use of interpreters were
issues mentioned by almost all respondents in this study
and are commonly covered in the literature on migrant
health care. Qualitative studies with refugees and asylum
seekers in the United Kingdom highlighted the concerns
patients had in trusting professional interpreters to
maintain confidentiality [25]. Studies from the United
States mirror the concern in using interpreters, even
professional ones, as errors were documented in inter-
pretations that entailed real clinical consequences, such
as misdiagnosis and inadequate treatment [26].
Language barriers, different cultural norms, and different
understandings of illness and treatment were identified as
separate themes in this study, whilst in the literature they
are often linked as obstacles to care experienced by both
patients and practitioners alike [27,28]. Recommendations
and interventions have tried to bridge the intercultural gap,
with results from a randomised control trial in the Nether-
lands indicating improvement in mutual understanding
after six months [29]. Overall, cultural differences appear
to receive less attention than language barriers, and may be
less considered in consultations with migrant patients [30].
Suggested ways forward include an increased awareness
among practitioners of cultural differences and the use of
advocates (not just interpreters) to increase mutual under-
standing without challenging more entrenched cultural
beliefs [31-33].
A wider concern is the implication that cultural sensitiv-
ity might give rise to individual migrants being treated by
ethnic group and by letting cultural expectations exceed
Priebe et al. BMC Public Health 2011, 11:187
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individual preference. Discrimination and xenophobia in
services were reported as a problem in providing care to
migrants [34-36], which relates to the problem theme of
negative attitudes in staff and patients in this study.
Implications for improving practice
The three most frequent components of good practice,
i.e. organisational flexibility with sufficient time and
resources, good interpreting services, and working with
families and social services, all related to changes at the
organisational level and the availability of sufficient
resources. Changes of organisational procedures, alloca-
tion of more time to patients with interpreting needs,
and involving other services in dealing with social and
legal affairs, would free practitioners to focus on deliver-
ing effective health care for all. This requires flexibility
within the service and a willingness to collaborate with
families and other services [37].
Other components of good practice advocated in this
study require practitioner training and the provision of
information to both health care staff and migrants. This
applies to increasing cultural awareness amongst staff, pro-
viding educational programmes and information material
for migrants, and circulating clear guidelines for staff on
the care entitlements of different migrant groups. Previous
research [5,9,10] suggests that knowledge of the health
care system and awareness through experience may
change the way migrants understand and utilise services,
resulting in a more appropriate use of non-emergency ser-
vices. Training and educational programmes may reduce
the time it takes for this transition of service use to occur.
Attitude changes were also reported in this study as cru-
cial to the delivery of good care. Where views of migrants,
and of practitioners, were considered entrenched in
stereotypes and unrealistic expectations, health care was
seen as negatively affected. Positive relationships with staff
and continuity of care were regarded as parts of good
practice and helpful for combating negative attitudes
towards care staff and migrant patients alike. Setting rea-
sonable expectations for what services and practitioners
can deliver may also reduce migrant patients notable
disappointment with services [15].
Conclusions
The findings show and reflect a rich experience of health
services across Europe in providing health care for
migrant patients. There is a wide agreement on the rele-
vant challenges and problems, which are not necessarily
linked to the specific origin of the migrant. Health care
professionals also have experiences and views about what
constitutes good practice. The extent to which all good
practice components are implemented varies, and there
is certainly a chance for services to learn from each other
and utilise experiences gained in other countries.
Page 11 of 12
Implementing all good practice components as identi-
fied in this study requires sufficient resources, organisa-
tional flexibility, positive attitudes, training for staff, and
the provision of information. The provision of sufficient
resources, e.g. for more practitioner time and good
interpreting services, is a challenge for commissioners
and funding agencies, and is likely to be influenced by
political priorities. Organisational flexibility does not
always depend on the provision of more resources and
may partly be achieved through appropriate policies and
protocols. Training of staff also absorbs resources,
and needs both the availability of effective training pro-
grammes and the interest of the staff to be trained.
Information material should not be too difficult and
costly to produce, although more evidence is required
for how best to design and disseminate such material.
The most challenging aspect to influence is probably
staff attitudes, which may be linked to personal experi-
ences as much as the wider societal context.
With respect to further research, the study shows that
qualitative material can be collected in a consistent way
across many countries and that an analysis of such
material can yield useful findings. Future observational
studies may be less comprehensive and address more
narrowly defined aspects, capture patient views, assess
actual behaviour in the services, and focus on service
models that are regarded as very good practice. Experi-
mental studies may test the feasibility and effectiveness
of specific interventions to achieve one or more of the
good practice components identified in this study.
Acknowledgements
This study is a part of the EUGATE project funded by the General Directorate of
Health and Consumer Protection of the European Union (DG-SANCO). More
information on the website: http://www.eugate.org.uk. All authors would like to
acknowledge the entire EUGATE research team, for their contributions to data
collection and management. We also acknowledge the 240 participants for
giving their time and for their willingness to share their experiences.
Author details
1
Unit for Social and Community Psychiatry, London and the Barts School of
Medicine and Dentistry, Queen Mary University of London, Newham Centre
for Mental Health, London, E13 8SP, UK. 2Institute of Hygiene and Tropical
Medicine, Universidade Nova de Lisboa, Rua da Junqueira, 96, 1349-008
Lisbon, Portugal. 3Public Health Agency for the Lazio Region, Via S. Costanza
53, 00185 Rome, Italy. 4Etablissement public de sant Maison Blanche, 3-5
rue Lespagnol, 75020 Paris, France. 5Department of Sociology, National
School of Public Health, 196 Alexandras avenue, Athens 11521, Greece.
6
Clinic for Psychiatry and Psychotherapy, Charit - University Medicine Berlin,
CCM, Charitplatz 1, 10117 Berlin, Germany. 7Danish Research Centre for
Migration, Ethnicity and Health (MESU), Unit of Health Services Research,
Department of Public Health, University of Copenhagen, ster Farimagsgade
5, DK-1014 Copenhagen, Denmark. 8International and Migrant Health, NIVEL
(Netherlands Institute for Health Services Research), Otterstraat 118-124, PO
Box 1568, 3500 BN Utrecht, The Netherlands. 9Institute of Health and Society,
Catholic University of Louvain, Clos Chapelle aux Champs 30.05., 1200
Brussels, Belgium. 10Agency of Public Health of Barcelona, Pa. Lesseps, 1,
08023 Barcelona, Spain. 11Faculty of Health Sciences at Nyregyhza,
University of Debrecen, Ssti t 31/B, 4400 Nyregyhza, Hungary.
12
Department of Public Health Sciences, Section of Social Medicine,
Priebe et al. BMC Public Health 2011, 11:187
http://www.biomedcentral.com/1471-2458/11/187
Karolinska Institutet, SE- 171 76 Stockholm, Sweden. 13Department of Health
Management, Lithuanian University of Health Sciences, A. Mickeviiaus g. 9,
LT 44307, Kaunas, Lithuania. 14Ludwig Boltzmann Institute for Social
Psychiatry, Lazarettgasse 14A-912, 1090 Vienna, Austria. 15National Institute
for Health and Welfare (THL), Department for Mental Health and Substance
Abuse Services, P.O.B. 30, FIN-00271 Helsinki, Finland. 16Institute of Psychiatry
and Neurology, Ul. Sobieskiego 9, 02-957 Warsaw, Poland.
Authors contributions
SP, SD, AG, TG, EI, UK, AK, ML, VL, RPR, AS, JJFS, MS, CS, KW, MW and MB all
made substantial contributions to the design of the interview study, data
collection, coding and initial stages of analysis, interpretation of the findings
and critical revision of drafts. MB further coordinated the analysis across
countries and centralised it in the UK. SS contributed to the analysis of
findings, and drafting of the manuscript for publication.
Competing interests
The authors declare that they have no competing interests.
Received: 6 December 2010 Accepted: 25 March 2011
Published: 25 March 2011
References
1. Herm A: Recent migration trends: Citizens of EU-27 Member States
become ever more mobile while EU remains attractive to non-EU
citizens. Eurostat - Statistics in Focus 2008.
2. United Nations Development Programme: Human Development Report 2009:
Overcoming Barriers - Human Mobility and Development. New York 2009.
3. Ivanov L, Buck K: Health care utilization patterns of Russian-speaking
immigrant women across age groups. Journal of Immigrant Health 2002,
4:17-27.
4. Cristancho S, Garces DM, Peters KE, Mueller BC: Listening to rural Hispanic
immigrants in the Midwest: A community-based participatory
assessment of major barriers to health care access and use. Qualitative
Health Research 2008, 18:633-646.
5. Leduc N, Proulx M: Patterns of health services utilization by recent
immigrants. Journal of Immigrant Health 2004, 6:15-27.
6. Perez-Rodriguez MM, Baca-Garcia E, Quintero-Gutierrez FJ, Gonzalez G, Saiz-
Gonzalez D, Botillo C, Basurte-Villamor I, Sevilla J, Gonzalez de Rivera JL:
Demand for psychiatric emergency services and immigration: Findings
in a Spanish hospital during the year 2003. European Journal of Public
Health 2006, 16:383-387.
7. Carrasco-Garrido P, Jimnez-Garca R, Hernndez Barrera V, Lpez de Andrs A, 32. Green G, Bardby H, Chan A, Lee M: We are not completely Westernised":
Gil de Miguel : Significant differences in the use of healthcare resources of
native-born and foreign born in Spain. BMC Public Health 2009, 9:201.
8. Hernndez-Quevedo C, Jimnez-Rubio D: A comparison of the health
status and health care utilization patterns between foreigners and the
national population in Spain: New evidence from the Spanish National
Health Survey. Social Science & Medicine 2009, 69:370-378.
9. Norredam M, Mygind A, Nielsen AS, Bagger J, Krasnik A: Motivation and
relevance of emergency room visits among immigrants and patients of
Danish origin. European Journal of Public Health 2007, 17:497-502.
10. Hargreaves S, Friedland JS, Gothard P, Saxena S, Millington H, Eliahoo J, Le
Feuvre P, Holmes A: Impact on and use of health services by
international migrants: questionnaire survey of inner city London A&E
attenders. BMC Health Services Research 2006, 6:153.
11. Sundquist J: Ethnicity as a risk factor for consultations in primary health
care and out-patient care. Scandinavian Journal of Primary Health Care
1993, 11:169-173.
12. Sundquist J: Swedish migration in a current, historic and international
perspective: Immigration put more demands on health care.
Lakartidningen 1998, 95:169-173.
13. Mladovsky P: Migrant health in the EU. Eurohealth 2007, 13:9-1.
14. Watters C: Migration and mental health in Europe: report of the preliminary
mapping exercise. Journal of Ethnic and Migration Studies 2002, 28:153-172.
15. Lindert J, Schouler-Ocak M, Heinz A, Priebe S: Mental health, health care
utilisation of migrants in Europe. European Psychiatry 2008, 23:14-20.
16. Norredam M, Nielsen SS, Krasnik A: Migrants utilization of somatic
healthcare services in Europe - a systematic review. European Journal of
Public Health 2010, 20:555-563.
Page 12 of 12
17. Hultsj S, Hjelm K: Immigrants in emergency care: Swedish health care
staffs experiences. International Nursing Review 2005, 52:276-285.
18. Abbott S, Riga M: Delivering services to the Bangladeshi community: The
views of healthcare professionals in East London. Public Health 2007,
121:935-941.
19. Priebe S, Bogic M, Adany R, Bjerre NV, Dauvrin M, Deville W, Dias S,
Gaddini A, Greacen T, Kluge U, Ioannidis E, Jensen NK, Puigpinsi Riera R,
Soares JJF, Stankunas M, Stramayr C, Wahlbeck K, Welbel M, McCabe R, for
the EUGATE group: Good practice in emergency care: Views from
practitioners. Migration and Health in Europe World Health Organisation.
Geneva, Switzerland: World Health Organisation.
20. Hsieh HF, Shannon SE: Three Approaches to Qualitative Content Analysis.
Qualitative Health Research 2005, 15:1277-1288.
21. Patton MQ: Qualitative Research and Evaluation Methods. Third edition.
Thousand Oaks, CA: Sage; 1970.
22. Silverman D: Interpreting Qualitative Data: Methods for Analysing Talk, Text
and Interaction. Second edition. London: Sage; 2001.
23. Gilgen D, Maeusezahl D, Salis Gross C, Battegay E, Flubacher P, Tanner M,
Weiss MG, Hatz C: Impact of migration on illness experience and help-
seeking strategies of patients from Turkey and Bosnia in primary health
care in Basel. Health and Place 2005, 11:261-273.
24. Lindert J, von Ehrenstein OS, Priebe S, Mielck A, Brhlar E: Depression and
anxiety in labor migrants and refuges - A systematic review and meta-
analysis. Social Science & Medicine 2009, 69:246-257.
25. Bhatia R, Wallace P: Experiences of refugees and asylum seekers in
general practice: a qualitative study. BMC Family Practice 2007, 8:48.
26. Flores G, Barton Laws M, Mayo SJ, Zuckerman B, Abreu M, Medina L,
Hardt EJ: Errors in medical interpretation and their potential clinical
consequences in paediatric encounters. Paediatrics 2003, 111:6-14.
27. Ferguson WJ, Candib JM: Culture, language, and the doctor-patient
relationship. Family Medicine 2002, 34:353-361.
28. Van Wieringen JC, Harmsen JA, Bruijzeels MA: Intercultural communication
in general practice. European Journal of Public Health 2002, 12:63-68.
29. Harmsen H, Bernsen R, Meeuwesen L, Thomas S, Dorrenboom G, Pinto D,
Bruijnzeel M: The effect of educational intervention on intercultural
communication: Results from a randomised controlled trial. British
Journal of General Practice 2005, 55:343-350.
30. Wachtler C, Brorsson A, Troein M: Meeting and treating cultural difference in
primary care: a qualitative interview study. Family Practice 2006, 23:111-115.
31. Chen AW, Kazanjian A, Wong H: Why do Chinese Canadians not consult
mental health services: Health status, language or culture? Transcultural
Psychiatry 2009, 46:623-641.
Dual medical systems and pathways to health care among Chinese
migrant women in England. Social Science & Medicine 2006, 26:1498-1506.
33. Reiff M, Zakat H, Weingarten MA: Illness and treatment perceptions of
Ethiopian immigrants and their doctors in Israel. American Journal of
Public Health 1999, 89:1814-1818.
34. Blignault I, Ponzio V, Rong Y, Eisenbruch M: A qualitative study of barriers
to mental health services utilisation among migrants from mainland
China in South-East Sydney. International Journal of Social Psychiatry 2008,
54:180-190.
35. Doescher MP, Saver BG, Franks P, Fiscella K: Racial and ethnic disparities in
perceptions on physician style and trust. Achieves of Family Medicine 2000,
9:1156-1163.
36. Watters C: Migration and mental health in Europe: report of the
preliminary mapping exercise. Journal of Ethnic and Migration Studies
2002, 28:153-172.
37. Nadeau L, Measham T: Immigrants and mental health services: Increasing
collaboration with other service providers. The Canadian child and
Adolescent Psychiatry Review 2005, 14:73-76.
Pre-publication history
The pre-publication history for this paper can be accessed here:
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doi:10.1186/1471-2458-11-187
Cite this article as: Priebe et al.: Good practice in health care for
migrants: views and experiences of care professionals in 16 European
countries. BMC Public Health 2011 11:187.